At long last I have received the approval letter from the Research Ethics Committee! Don’t get too excited…I still have to get the necessary approval from the Ministry of Health. Originally, the thought was that the approval from the Ministry would take two days. Then again, I was supposed to have my letter from the Research Ethics Committee nearly two weeks ago, so I’m not getting my hopes up. If we do manage to get the approval from the Ministry by the end of this week, then Elena should actually be able to do the focus groups before she leaves, so it could potentially still work out.

Since the endless hours of waiting and transcription are boring enough without having to write a post about it, I figured I would write my long overdue post about our safari in Swaziland. In all fairness, though, because of the sluggish internet, it took me weeks to upload these things…one video clip took 763 minutes and that was after several failed attempts.

We went to Hlane Royal National Park with a great group of American students who we stayed with at Veki’s Guesthouse in Mbabane. This is the second time I’ve been to Hlane for less than 24 hours (though this time it wasn’t preceded by an 8 hour drive from Lesotho and sleeping in a very tiny car at the border…but that’s another story). In the short time we were there, I managed to get 3 game drives in (mid-day, sunset, and sunrise), and got to see pretty much everything. I was particularly psyched about seeing the giraffes (since I didn’t get to see them last time), but there really isn’t anything that gets your heart pumping like a full grown male lion 20 feet away who roars angrily when one of your safari-mates decides to stand up in the land-rover.

By my last game drive, I still hadn’t seen any elephants, so I was particularly excited when we finally came across a young elephant. The youngster was enjoying some breakfast alongside the road about 10 feet to our left and a whole herd was also grazing about 50 feet to our right. We took about 60 seconds worth of pictures when the young elephant starts crossing right in front of the jeep. Great picture taking opportunity, right? Wrong! Very suddenly, our guide floors it, forcing the elephant into a run and off the road. Irritated with our guide for interrupting our only elephant sighting, we ask for an explanation when he finally slows down several minutes later. He indicates the broken stub where the driver side mirror used to be attached and explains that not even one year ago, the same young elephant cried out to mama elephant for help when our guide’s land-rover was nearby. Before the guide could get away, mama charged and the land-rover went rolling over with its 8 German passengers. Since that day, mama still charges when she sees the land-rover. It turns out that the young elephant was trying to set us up for a ramming! So not only did we not get any good elephant pictures, we also missed an opportunity for a great story…lucky Germans!

In addition to our safari fun, we had an interesting dinner (impala pot roast), some great entertainment provided by a roaming ostrich, and a great campfire that we managed to start without even resorting to the oil from our lamps (my father-in-law would have been so proud of my fire-starting abilities!). Thanks to Elena, Michelle, Ben and Lauren (aka “Little L” – yes, that does make me Big L) for a great safari!

I thought perhaps the Research Ethics Committee would decide to give me an approval for my Anniversary, but still no luck. Instead, I got to transcribe one hour and 37 minutes of an interview with a hammer banging loudly in the background and a squeaky door swinging open and closed. At least Elena did an awesome job of note-taking, so it’s not nearly as painful as it could have been. Elena and I continue to be entertained by some of our initial misinterpretations (i.e. “there is a stance” instead of “the resistance” and “paper beans” instead of “paper bins”), but it makes me all the more grateful to have two sets of ears listening to tricky parts of the recordings.

I’m now trying to make some informal appointments with some health workers to get a sense of their experiences in implementing accreditation so that Elena and I can better prepare for the focus groups that she will now, almost certainly (with any luck) be conducting on her own after I leave. Since we don’t have the formal approval, we can’t go through the official hospital channels despite the fact that these discussions wouldn’t actually be part of the research, so we’re relying on friends of friends. Here’s hoping!

Despite my feelings of regret at extending my stay, tonight erased any bit of regret I might have…although not for any professional reasons. Elena and I spent a wonderful evening with Abraham and Ruth Chikasa and their family. Their teenage kids actually prepared an amazing feast for us (I really need to figure out the trick to this before I have kids) and we had the most pleasant conversation…the perfect combination of fun and relaxation. We learned more about Zambian history and culture in one evening than we have in two weeks here. If I had to spend my anniversary away from Buck, this was about as good as it gets.

To escape the confines of the guest house where we’ve been holed up transcribing most days, I took the bus down to Manda Hill shopping plaza where they have a great little café that was referred through the expat community. On my way back, I made a class rookie mistake. You see, I’ve become quite spoiled in Lesotho and it’s been several years since I’ve had to take a kombi, so I was unprepared for the minibus madness.

As I was leaving the shopping center, I had several conductors approach me. Rather than choosing quickly and moving confidently to the minibus of my choice, I allowed the conductors to fight over me until I found myself pushed into the door of the one closest to me. As I was being corralled, I was so busy kicking myself for my mistake that I got distracted from watching the hands of those corralling me. And so I bid adieu to my new computer mouse. What a Zambian conductor is going to do with a wireless mouse sans receiver is beyond me. At least that’s all they got. I hate minibuses.

I’m really starting to hate the tomorrow game. The tomorrow game convinced me to extend my stay in Zambia by a week. The tomorrow game led me to believe that I would have the necessary approval from the Research Ethics Committee at the end of last week and the necessary approval from the Ministry by the end of this week. The tomorrow game pushed me to tentatively schedule focus groups for next week. The tomorrow game is killing me. No approvals. But of course, the approval is coming tomorrow.

Each day has been the same roller coaster. I wake up hopeful that today will be the day. By mid-morning, I’m disappointed that I haven’t gotten a letter yet. By lunchtime, I start feeling really sorry for myself and I’m kicking myself for extending my stay. At the end of the day, I have a conversation that fools me into thinking that I’ll get the approval the next morning. And then the roller coaster starts again with the hopeful morning. I desperately want off this ride.

In an attempt to cope with this, I am doing what I do best…making plans. I love plans. Plans give me purpose and direction and take away some of the anxiety that I feel in the face of uncertainty. As long as the plans encompass the full range of likely scenarios (from best case to worst case), you can’t go wrong. So here it goes:

Plan Awesome will be enacted if I get the approval by the end of the day Monday (July 12th). I hold focus groups and administer surveys on Tuesday, Wednesday, and Thursday and hold key informant interviews on Tuesday afternoon and Friday. Elena holds a fourth focus group and collects surveys the following week while I wrap up my last key informant interviews from Boston, thus completing all data collection in 60 days. I would say the odds of this happening are about 1% at this point, but I never count out the power of prayer.

Plan B will go into motion if I get the approval by the end of the day next Wednesday (July 14th). I conduct as many key informant interviews as possible and one focus group on Thursday and Friday. Elena spends the following week holding focus groups and administering surveys while I wrap up my last key informant interviews from Boston. We then make arrangements with the local Boston University office to collect the administered surveys, thus completing all data collection in about 65 days. I’m gonna give this about a 20% chance of happening.

Plan C is the course of action we will take if I get the approval at any point after I leave and before Friday, July 23rd. Elena does as many focus groups as she possibly can and administers the surveys. I do key informant interviews by phone (less than ideal) and the local BU office collects the surveys, thus completing all data collection within 70 days. I’m guessing there’s a 30% chance of this happening.

Worst case scenario, I don’t get the approval before Elena leaves, which will mean surveys are administered by email, all key informant interviews by phone, and no focus group data. This would be a major bummer and totally destroy my hopes of not having every moment of my summer completely monopolized by data collection, but at the end of the day, it’s still something and with the data from Lesotho and Swaziland, still plenty for a dissertation and to answer my research question.

AND the bonus to all of this is that we are catching up on transcription, so at least my extra week off isn’t a total waste regardless. Although I’m not sure it will really pay off, I owe the folks at COLMR a big thank you for being so understanding and allowing me the extra week of leave. I may regret taking the week if we don’t get the approval in time, but not as much as I would regret not taking the week if we do get it in time. So if you’re reading, thank you!

In my few days here, I feel like I’ve been to two Lusaka’s. The first Lusaka was big and overwhelming and scary, and I had no interest in exposing myself any more than necessary to it’s busy highways, sprawling neighborhoods, unfamiliar faces, and multiple languages. Our first two days here, we saw the guesthouse, the BU office, the lobby of the Ministry of Health, and the grocery store. We walked the 25 minutes from our guesthouse to the BU office all through residential areas that represented a fraction of a percent of Lusaka. In Lesotho, you can walk from one end of Maseru’s city center to the other in less than that. By the end of our first week in Swaziland, we knew all the major streets in Mbabane. This first Lusaka completely overwhelmed me and made me feel very much off my game. And the lack of success during our first couple days made me feel that much more intimidated by this mammoth country I know so little about.

I started to discover the second Lusaka during dinner at the Kalahari last night. Getting support from the Ministry of Health made me feel a bit warmer towards Zambia, so we were a bit more adventurous today. We wanted to visit the offices of the Churches Health Association of Zambia (CHAZ) to introduce ourselves and the study. Their offices were sandwiched exactly in the area that we were told to be wary of (halfway between Cairo Road and Lumumba Road). But rather than criminals, we met only people who went out of their way to ensure our safety. The taxi driver who took us to the offices instructed me not to put my purse in my lap lest someone snatch it through the open window. On our way out of the offices, the CHAZ guard wouldn’t allow us to leave the premises without finding us a taxi driver who he knew and trusted. We then went to meet a friend, Ruth Chikasa, at her shop on Cairo Road. We went out for lunch together, and had a great time catching up and talking about all the festivities around her niece’s upcoming wedding. She then insisted on finding us “her guy” to drive us safely to the University. So despite all the warnings, we have only encountered the kindest, most helpful, and protective individuals. I will be careful to not let my guard down completely, but I am really looking forward to experiencing more of this second Lusaka, which feels a much friendlier, much more inviting, much less intimidating place.

And for the first time since we arrived, we had a very full day (never thought I would be so happy about a packed schedule). After a full morning of dropping by offices at various institutions to introduce ourselves, we headed to the University of Zambia Research Ethics Committee to receive their comments (aka our sentence). They requested that our local supervisor feature more prominently in the application and that we include our local contact details, not just our U.S. contact information. That’s it. Amazing. After 2 months. We rushed back to the guesthouse to make the few changes and resubmit. Assuming that the Chair doesn’t take off early for the weekend, we should actually have an approval letter from the Research Ethics Committee by the end of the day tomorrow. Don’t get too excited…we still have to get the approval from the Ministry of Health. Keep praying!

After a rather exhausting day, we find out that the guesthouse wants us to change rooms a third time…this is particularly interesting since they only have four rooms. After several years of traveling back and forth to Lesotho, I discovered that I function much better if I completely settle in to my temporary home since living out of a suitcase leaves me feeling constantly scattered. My method usually works just fine…not today. It took over an hour to transfer all our things from one room to the other. I was very glad that I had negotiated a free dinner for us in exchange for the inconvenience, and it was oh so worth it…the best food we’ve had on our travels yet. If anyone wants a fabulous meal in Lusaka, eat at the Nena’s Guesthouse Restaurant…just be sure you have a few hours to spare when you go.

We had a rather comical arrival in Zambia. I carried my 3 foot tall giraffe, Murphy (don’t ask), wrapped in bubble wrap, and he actually flew in the cockpit on our flight there. Elena accidentally brought her scissors and pocket-knife on the plane. And it was only after we had landed that we learned of the US$50 visa fee per person, for which we of course were completely unprepared. I looked and felt very much like a completely inexperienced, rookie traveler.

By the end of our first day, I was very discouraged. A whole day with no meetings, no potential meetings, and no leads to potential meetings. I was no better off than I was two months ago. By the end of the second day, I started thinking about throwing in the towel and going home early. I dreaded writing a post of my failure. Oh, how quickly things change.

Day 3. Today started out as disappointing as the rest of them. Then just before lunch, we met with a representative from the University of Zambia Research Ethics Committee. Although the study had been expedited, the reviewers apparently couldn’t come to consensus, so it had to be referred to the full board. We were assured that the study would be reviewed by the board this afternoon, and it would likely get a conditional approval that might request a few issues to be addressed, but could then be approved quickly after they are addressed. Interesting that the study has been approved by the BU IRB, the Lesotho Research Ethics Committee, and the Swaziland Scientific Ethics Committee, but there are issues with it now. My hope is that it’s something fairly minor that I can respond to by the end of the day and get it all sorted out rather quickly. We hear tomorrow. Pray hard!

Then we had a fantastic meeting with my knight in shining armor from the Ministry of Health (MOH), who was so clearly an answer to prayer. His guidance is what I am sure will ensure the success of our work here. He completely understands the sense of urgency around the data collection, and he will help to facilitate the necessary approvals. He provided us with a list of names and numbers for our key informants and names and numbers for key contacts at a great representative mix of hospitals in Lusaka and Southern Provinces. I still have to worry about the timing of the approvals, so I am far from being in the clear, but I’ve got renewed hope. Even moreso, I know that we HAVE to be successful because we owe it to our MOH hero to produce something that will be useful to him and to the Ministry.

In the spirit of USA’s recent win against Algeria, I thought I would finally write a post of our World Cup adventure. First, you have to know that Elena and I had talked about going to the USA-England game, but several attempts at getting tickets had fallen through. A couple days before the game, we finally accepted that it just wasn’t going to happen. Elena made plans to have a nice lunch in Johannesburg with an American friend she met in Egypt and dinner plans with a South African friend she met in Santa Barbara, who we were staying with Saturday night. We started looking forward to our peaceful weekend.

Saturday, June 12th – GAME DAY

11:30 am. Elena and I are 50km down the road from Bloemfontein on our way to Johannesburg when Elena calls to confirm our lunch plans with Jackie. Jackie informs us that she has a friend of a friend of a friend who can sell us tickets to the game. We’re not really sure how likely it is that the guy will actually have tickets for us when we get to the game, but we decide to go for it anyway. We start booking it to Johannesburg.

3:00 pm. We arrive in Johannesburg and pick Jackie up at her hostel and then book it to Andrea’s place in Pretoria. On the way Jackie makes her first call to John, our ticket guy, with the update on our status. He still has the tickets.

4:00 pm. We arrive in Pretoria to pick up Elena’s friend, Andrea. Andrea, the South African in the group, had enough USA gear for all of us. She came with car flag, scarf, and stickers for the lot of us. She also got us some awesome meat pies for the road…no stopping now! Back in the car and off to Rustenburg! Jackie makes her second call to John while I drive with great speed and determination (and of course safely and with seatbelts fastened) towards the stadium.

5:00 pm. We’re 18km away from Rustenburg and we hit our first traffic jam. 30 minutes and 5 phone calls to John with status updates later, we make it through the toll booth that was causing the traffic jam and we start moving again.

6:00 pm. Now we’re stuck. The traffic is barely moving. We’re all super irritated with the people who think they’re more important than everybody else and decide to turn the berm into an extra lane. I straddle the lane and the berm to block the ruffians, but the car of French people behind us don’t appreciate my law enforcement efforts (or perhaps it’s the American flag that Andrea is waving proudly out the window that they don’t appreciate) and try to push us out. Eventually, we decide that we too are more important than everyone else and zip down the berm…hiding our faces (and our flag) in shame of course.

7:30 pm. Jackie makes her 18th call to John to tell him that we’re nearly at the parking lot. Apparently, all the calls and texts ran down his phone battery and he warns us that his phone is about to die. We are to meet him at Gate B where he will wait for us with the tickets.

7:45 pm. We arrive at the parking lot. Park. Grab stuff. Lock doors. RUN! We start our first sprint to the shuttles taking fans from the lot to the stadium. We get on the shuttle with a bunch of other USA fans where we realize that we don’t have any kind of soccer team song that we can sing. So we break out into Sweet Caroline…the next best thing.

8:00 pm. The shuttle arrives at the stadium. Park. Jump. RUN! We start our second sprint from the shuttles about 0.5 km to Entrance 5.

8:05 pm. We arrive at Entrance 5 and go through 2 rounds of security before we find out that we can’t get to Gate B without the tickets. Jackie calls John, but his phone is dead. We find out that Gate B is closer to Entrance 2 at the other side of the stadium. RUN! We start our third sprint from Entrance 5 to Entrance 2. The park is designed so that you have to run the perimeter around the perimeter around the perimeter to get from one side to the other from outside the stadium…about 1.5 km.

8:20 pm. We arrive sweating and gasping for air at Entrance 2, but no sign of John and no way to reach him. 5, 7, 10 minutes go by. The game is supposed to start and we’re stuck outside. We’re just about to give up when Jackie’s phone rings. John’s friend to the rescue! He’s waiting at Entrance 5. Seriously?! But he says he’ll run to Entrance 2 and meet us there.

8:35 pm. We’re waiting for John’s friend. We hear cheers from the stadium…the game has started. They start closing the gates, and we beg for more time.

8:38 pm. We see a guy running towards us. We run at him and all of us embrace in a giant, jumping, group hug. We run shrieking and skipping towards the security guards who barely looked at our tickets in amusement at our excitement and/or sympathy for our urgency to get inside the stadium. RUN! We run now towards Section J, not because we have to but because we are so excited to actually be through the gates to the stadium.

8:42 pm. We step foot inside the stadium…it was magic, pure magic. We all look at each other and share a group scream before we take the world’s best seats…midfield, row P…16th row back. The game is incredible. Words can’t even describe it…a couple of the best hours ever.

10:30 pm. Then all of a sudden it’s over. The screens aren’t working at the stadium, so we have no way of knowing that the game time is coming to an end. Just as quickly as it all started, it ends…at least the game ends.

10:35 pm. The post-game celebrations begin. The tied score left everyone feeling like winners, so US and England fans celebrate together. We dance on the seats, take pictures, and make friends, and we finally leave when the guards kick us out.

11:00 pm. We leave the stadium and then Jackie starts a dance party in the port-o-potty lines so after another 20 minutes of dancing, we finally head to the lines for the shuttles. Jackie finds a way around the line so we get a shuttle right away and we are on the road back to Pretoria by 11:45 pm…just a little over 12 hours after we made that initial call to Jackie.

We’re making incredible progress. I really hadn’t expected to actually meet all data collection goals in 2 countries, but it looks like we’re on track to do just that. We had our second focus group today and our fourth key informant interview. We’ve got one more of each and then surveys and then we’re done in Swaziland. I’m feeling a bit overwhelmed with the amount of transcription that needs to be done…and then of course the coding and analysis of the data is after that. Don’t get me wrong – it’s a completely wonderful overwhelmed, not at all like the awful overwhelmed feeling I had when all this started and I wasn’t sure I was going to get any data. I’m still not sure how things will work out in Zambia, but I’ve certainly got enough data now to keep me busy for a while, so it definitely takes some of the pressure off.

The content of the focus groups has been great. Since Swaziland is currently implementing the model of accreditation that Lesotho plans to adopt, we’ve been asking participants in Swaziland what their advice would be to Lesotho. The responses have been great. The suggestions for improvement of the current model and the rich descriptions of the key ingredients for success have been great. At the start of this, I had planned to do a within-country analysis to share with each country in addition to the overall papers that would cut across countries. What I realize now is that each individual country may actually benefit as much if not more from our findings in the neighboring countries. And I am really excited about how useful this information will be to the current accrediting bodies in the region.

The logistics of the focus groups have had a few kinks. They’ve all started about 30-45 minutes late, which is, of course, expected. But providing lunch has been particularly challenging. It never works out as we expect. Today, we were expecting lunch to arrive at 1 for the participants when we discovered that we had to actually go in person. One of the participants offered to drive half of the participants and then we crammed 5 in our tiny car, which only technically seats 4 people including the driver. It was way less comfortable than a kombi, but we made it. We know now to always expect the worst when it comes to organizing lunch.

Actually, we were quite happy that they were serving hake in addition to the chicken for lunch since we were in a foot-and-mouth disease area. We had no idea what this meant other than the fact that livestock were prohibited from leaving the area. Since we weren’t sure what livestock were affected, we figured we would play it safe. At least until Elena opted for the chicken on her second trip to the buffet. We had a lot of fun guessing about the possible symptoms of foot-and-mouth disease that Elena may start experiencing at any moment until we got onto the internet and found that it only affects cloven-hoofed animals and rarely infects humans. So next time you’re in a foot-and-mouth disease area, go ahead and eat the chicken!

I had planned to take a day to rest and relax…I would sleep in, take a short trip to the Manzini Market, sit outside in the sun to read a book, go for a walk around town, and maybe even take a nap. It was certainly a day off, but not the lazy one I had planned. I woke up at 7:15 and felt the urge to do some transcribing. By 10, I was headed for the Manzini Market, where I bought a bunch of earrings and a 3 foot tall giraffe…this is going to be fun to try to get on the plane. Then I headed to meet some of my fellow guesthouse-mates for a bike ride through the Mlilwane Wilderness Reserve.

I pictured a short leisurely ride through the park. Instead, we hopped on our mountain bikes and started our 55km bike ride…35km of which was just getting to and from the park. I was completely unprepared for this to say the least. No sunscreen, no pack, no way to put my hair in a ponytail, no spare camera battery, and perhaps most importantly, no skills on a bike whatsoever. It was well worth it though. Biking is a great way to safari…you move too slow while walking and you miss too much while driving. The only tricky bit is taking pictures while also trying to control your bike, but you quickly figure out how to do this. The zebras were my favorite part, but we also saw a crocodile, hippos, and plenty of wildebeests, springboks, and impalas. And this was just a wilderness reserve…can’t wait for the big game parks!

This is my attempt to take a picture of myself while riding a bike...it's harder than you think.

Although we have yet to analyze the surveys for Lesotho, we were very impressed with how thoughtfully and thoroughly they were completed. Even though comments were optional, we got some really great feedback. This was the only thing that kept us going for the last full 3 days late into the night to do all the printing and sorting (hence the lack of blog posting).

How we've spent the last 3 days and nights.

Elena and I have finally finished putting together the surveys for Swaziland. 140 pages worth of standards to rate compared to Lesotho’s 40. This took considerable reworking. Obviously, we couldn’t ask any single individual to rate all 140 pages of standards. So with a slight increase in our survey sample size (from 20 people to 90), we’ve managed to split up the standards into pieces and include both senior leadership and department heads in the rating. This also means going to all 6 hospitals in the country in order to find enough leaders. Even if every single hospital leader in the country completed their part of the survey, we would only get 12 full ratings, so we’re really hoping for high rates of return.